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Caesarean section in the Islamic Republic of Iran: Prevalence and some sociodemographic correlates
Abstract and Figures
The aim of this study was to investigate the prevalence of caesarean section in the Islamic Republic of Iran in different provinces and to compare the sociodemographic characteristics of married women with and without caesarean section. Data were analysed from the Iranian Demographic and Health Survey of a representative sample of married women (n = 17,991) who delivered a baby between September 1998 and October 2000. Overall, 35.0% of deliveries were by caesarean section. Women having a caesarean section were older, better educated, married at a later age and with lower parity than those who delivered normally. Provincial variations in rates were significantly correlated with indices of socioeconomic development.
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... Rising CB around the world has driven public health practitioners to address the determinants of this increase. Until now, the major determinants of the rise in CB were assumed to be related to multiple factors ranging from certain obstetric risks such as dystocia, fetal distress, breech births, post-term pregnancy, multiple pregnancy, and hypertensive disorder 14,15 ; sociodemographic factors such as higher maternal age, higher birth order, urban residence, higher socioeconomic status (SES) 16,17 ; psychological factors such as fear related to prolonged labor and vaginal delivery pain 18 ; and factors related to physicians' decisions and patient demand. 19 There is also increasing evidence that maternal somatic phenotype, such as maternal short stature 20,21 and maternal overweight/obesity 22,23 have been independently associated with an increased risk of CB. ...
... Our findings are consistent with those of previous studies suggesting that women with higher education, women from urban areas, and older women were more likely to have cesarean deliveries, 7,16,17 and that higher parity women, 50 women belonging to the middle-to-high SES group, 51 and women with small babies at birth 52 had a higher probability of CB delivery in the SA region. ...
Background
The aim was to investigate: (a) whether there is an association between the maternal double burden of overweight and short stature and the risk of cesarean delivery and (b) whether socioeconomic status (SES) acts as a moderator in the association between the maternal double burden of overweight and short stature and the risk of cesarean birth (CB).
Materials and methods
The data for this study were obtained from the nationally representative Demographic and Health Survey databases of five South Asian countries. The analyses were based on responses from married women between 15 and 49 years of age. The risk of CB was the primary outcome, while the maternal double burden of overweight and short stature (coexistence of overweight and short stature) was the exposure of interest.
Results
Maternal double burden of overweight and short stature was significantly associated with 179% higher likelihood of undergoing CB in South Asia (SA), with 304%, 200%, 167%, 155%, and 125% higher likelihood of undergoing CB in Nepal, Pakistan, India, Maldives, and Bangladesh, respectively. Findings also demonstrated that mothers belonging to low SES groups with a double overweight and short stature burden were not uniquely disadvantaged.
Conclusions
A significant marker in SA of higher risk of CB is the maternal double burden of overweight and short stature. The negative effect of the maternal double burden of overweight and short stature extends across all economic backgrounds in relation to the risk of CB. It is not limited to poor mothers who suffer from the double burden of overweight and short stature.
... They were more likely to be older, primiparous, with lower gestational age, and have newborns with LBW or macrosomia. Higher maternal age [6,18] and primiparity [33,34] as factors influencing the C-section rate have been reported in previous research. There is a general consensus that the reported rise in C-section rates is often due to the presence of comorbidities either underlying or induced by pregnancy, such as diabetes, and hypertension [33]. ...
Background
The COVID-19 pandemic and its impact on healthcare services is likely to affect birth outcomes including the delivery mode. However, recent evidence has been conflicting in this regard. The study aimed to assess changes to C-section rate during the COVID-19 pandemic in Iran.
Methods
This is a retrospective analysis of electronic medical records of women delivered in the maternity department of hospitals in all provinces of Iran before the COVID-19 pandemic (February-August 30, 2019) and during the pandemic (February-August 30, 2020). Data were collected through the Iranian Maternal and Neonatal Network (IMAN), a country-wide electronic health record database management system for maternal and neonatal information. A total of 1,208,671 medical records were analyzed using the SPSS software version 22. The differences in C-section rates according to the studied variables were tested using the χ2 test. A logistic regression analysis was conducted to determine the factors associated with C-section.
Results
A significant rise was observed in the rates of C-section during the pandemic compared to the pre-pandemic (52.9% vs 50.8%; p = .001). The rates for preeclampsia (3.0% vs 1.3%), gestational diabetes (6.1% vs 3.0%), preterm birth (11.6% vs 6.9%), IUGR (1.2% vs 0.4%), LBW (11.2% vs 7.8%), and low Apgar score at first minute (4.2% vs 3.2%) were higher in women who delivered by C-section compared to those with normal delivery (P = .001).
Conclusions
The overall C-section rate during the first wave of COVID-19 pandemic was significantly higher than the pre-pandemic period. C-section was associated with adverse maternal and neonatal outcomes. Thus, preventing the overuse of C-section especially during pandemic becomes an urgent need for maternal and neonatal health in Iran.
... In the United Kingdom in 1953, only 2% of all recorded deliveries were cesarean deliveries but the rate continues to increase reached 21% in 2001 4 . In developing countries like Iran, the rate rose from 35% in 2000 to 47% in 2005 5 . The global concern around CS rates is understandable. ...
Background: Caesarean Section rates are progressively increasing in most parts of the world. It is an important role can improve infant and or maternal outcomes. However, when used inappropriately the potential harm may exceed the potential benefit of caesarean section. Objective: This study was conducted to determine socio-demographic characteristics of the study sample, to determine reasons associated with selection of elective caesarean section and to find out the relationship between reasons of cesarean section and some socio-demographic characteristics. Methods: This cross-sectional study was conducted from Dec17th 2017 to April 25 th 2018 in Ranya District, Kurdistan region. A quantitative design descriptive study was conducted on 64 women delivered abdominally at maternal and child Hospital and from outpatient clinics In Ranya District. Data regarding sociodemographic characters and reasons to conduct elective caesarean section was collected in a special designed questionnaire. Results: There was significant difference between Family incomes with regard to the reasons for elective caesarean section. The study found that a majority of the women surveyed 81.2% verbalized understanding that caesarean section was dangerous and is critical medical decision and situation despite this the fear and pain of normal delivery and vaginal dilatation in future had more impact on their decision to have a caesarean section with 85.9% of the women surveyed. Conclusion: Fear and pain of normal delivery is the main reason behind many women's preference for elective caesarean section in addition societal reasons such as inequality of care has changed the concept of good and normal birthing. Reduction of elective caesarean section cannot be achieved without regulating caesarean section use for primiparous in the Private Hospitals.
... Of the total cases of vaginal births, only 11.8% were performed in private hospitals and the rest in public centers[37]. In the present study, only 5% of the mothers in the intervention group referring to private hospitals performed a vaginal birth, while in one of the public hospitals, 71% of the mothers in the intervention group referring to that hospital performed a vaginal birth. ...
Background: Fear of childbirth is one of the major problems during pregnancy and the post-partum period that affects women’s health and preference for cesarean birth.
Objectives: The present study aimed to investigate the effect of midwife-oriented education and counseling on the type and consequences of childbirth in first-time pregnant women with fear of childbirth.
Methods: The present study is a single-blind randomized controlled trial performed on 122 first-time pregnant women with fear of childbirth. The samples were selected by the convenient sampling method and divided into two intervention and control groups by the four-blocked randomization method. Data collection tools were a demographic questionnaire and the Wijma Delivery Expectancy/Experience Questionnaire (WDEQ; version A before childbirth and version B after childbirth). The intervention was performed in the form of six counseling sessions based on the Gamble approach. The data were analyzed at a significance level of 0.05 using SPSS 21 statistical software.
Results: Regarding the effect of midwife-oriented counseling on pre-partum and post-partum fear, no statistically significant difference was observed between the two groups. The rate of choosing vaginal birth in the intervention group significantly increased after receiving counseling (p = 0.001). The frequency of vaginal birth, childbirth satisfaction, and childbirth consequences was not statistically significant between the two groups.
Conclusion: The present counseling method can be effective in increasing choosing vaginal birth in first-time pregnant women with fear of childbirth, but further research is required to evaluate its effectiveness on the maternal and neonatal consequences.
... In Iran, recent studies reported about seven-fold increase in the cesarean section rate; from less than 7% in the 1970s to over 48% in 2018 [4,[6][7][8][9]. The rate was reported to be higher in private hospitals (72-89%) [10][11][12][13]. ...
Abstract Background Predicting the success of vaginal delivery is an important issue in preventing adverse maternal and neonatal outcomes. Thus, this study aimed to compare the success rate of vaginal birth by using trans-labial ultrasound and vaginal examination, and vaginal examination only in pregnant women with labor induction. Methods This was a comparative study including 392 eligible pregnant women with labor induction attending to a teaching hospital affiliated with Iran University of Medical Sciences from April to October 2018 in Tehran, Iran. Women were randomly assigned to two groups; the trans-labial ultrasound plus vaginal examination (group A), and the vaginal examination only (group B). Women were included in the study if they satisfied the following criteria: singleton pregnancy, 37 to 42 weeks of gestational age, fetal head presentation, a living fetus with no abnormalities, uncomplicated pregnancy, and no previous cesarean section or any uterine surgery. We used a partograph for both groups to assess the fetal head position and the fetal head station. In group 1, the Angle of Progression (AoP) and Rotation Angle (RA) were also assessed. Finally, the success and progression of vaginal delivery in two groups were compared by predicting the duration of delivery and mode of delivery. Results The findings showed that 8.68% of women in the trans-labial plus vaginal examination group delivered by cesarean section, while 6.13% in the vaginal examination only group delivered by cesarean section (P = 0.55). In women with cesarean section in positive fetal head stations, Angle of Progression (AoP) was significantly decreased ranging from 90 to 135 degrees compared to women who delivered vaginally (135–180 degrees; P
Background: This randomized controlled trial aimed at comparing the effects of "motivational interviewing" and "information, motivation and behavioral skills" counseling interventions on choosing the mode of delivery in pregnant women in Tehran, Iran.
Methods: In a four-armed, parallel-design randomized controlled trial, 120 women were randomly assigned to three interventions and one control groups. The intervention groups included the following: 1) motivational interviewing (MI group); 2) face-to-face information, motivation, and behavioural skills training (IMB group); and 3) information, motivation, and behavioural skills training provided using a mobile application (IMB-App. group). The control group received usual antenatal care. The inclusion criteria included being in gestational age from 24 to 32 weeks at the time of recruitment, being literate, being able to speak Persian, and having no complications in the current pregnancy, having no indications for Cesarean section, and having enough time to participate in the study. The primary outcome of the study was the mode of delivery. The secondary outcomes included women's intentions to undergo Cesarean section (CS) and self-efficacy for choosing the mode of delivery.
Results: More than half of the women (56.7%) in the intervention groups preferred to undergo NVD. However, only 37.5% of them underwent NVD. The participants’ self-efficacy scores and intentions to choose the mode of delivery significantly increased (P < 0.05) in all three intervention groups. The participants in the IMB-App group reported significantly higher self-efficacy and intentions compared with the other two intervention groups and the control group.
Conclusions: Brief educational and motivation enhancement interventions could positively help pregnant women to choose normal vaginal delivery instead of unnecessary CS. Moreover, women's self-efficacy and intention to choose mode of delivery were improved in all three interventions, especially when offered using a mobile application. The use of non-expensive brief psycho-educational interventions may significantly reduce unnecessary CS, especially when combined with other evidence-based strategies to change healthcare providers’ practices and institutional policies.
Trial registration: This study has been registered in Iran's Randomized Clinical Trial Center (IRCT20151208025431N7), registered on (07/12/2018).
Objective:
The role of breast milk in the physical and mental health of infants and in the prevention of infant death is widely known. The benefits of breastfeeding for mothers and infants have been proven, but several factors can affect breastfeeding. Childbirth is one of the most influential factors. The present study aimed to investigate the effect of the type of delivery (natural childbirth and cesarean section) on breastfeeding based on the latch, audible swallowing, type of nipple, comfort, hold (LATCH) scoring system.
Methods:
The present cross-sectional observational study was performed using the census method among women who referred to Afzalipour Hospital for delivery in May 2020; the breastfeeding pattern was completed by observation and the in-case information, by LATCH checklist. Data were analyzed using the Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, IBM Corp., Armonk, NY, United States) software, version 19.0, analysis of variance (ANOVA), and the Chi-squared statistical test.
Results:
Out of a total of 254 deliveries (127 natural childbirths and 127 cesarean deliveries), there was no statistically significant difference between the 2 study groups in terms of age, maternal employment status, and infant weight, but there was a statistically significant relationship between the type of delivery, the maternal level of schooling, and the appearance, pulse, grimace, activity, and respiration (Apgar) score in the first minute. The mean score of breastfeeding patterns among the natural childbirth group (9.33) was higher than that of the cesarean section group (7.21).
Conclusion:
The type of delivery affects the mother's performance during breastfeeding, and mothers submitted to cesarean sections need more support and help in breastfeeding.
While rising Caesarean section rates have been the subject of much attention and debate worldwide, there is not much information available on this rate and its potential adverse impact in India.
Our survey was a standard Expanded Programme on Immunization 30-cluster design, carried out in an urban educated, middle/upper class population in Chennai. Mothers of 210 children aged 12-36 months were interviewed and data collected on immunization and breast-feeding practices. Since the mode of delivery was one of the questions, we could generate population-based data on the Caesarean section rate and its influence on breast-feeding.
Of the 210 babies, 95 (45%, 95% confidence interval: 39.1-51.3) had been delivered by Caesarean section. Two hundred and six of 210 babies (98%) had been breast-fed at some time. However, babies born by Caesarean section tended to be started late on breast-feeds were given prelacteal feeds more often, and colostrum less often when compared to babies delivered vaginally (all statistically significant).
Our study revealed a very high rate of Caesarean section in the selected metropolitan population. On purely scientific grounds, a rate of 40% to 50% is extremely difficult to justify. Though not conclusive, the data also suggest that Caesarean section may be adversely affecting some aspects of breast-feeding. There is a need for more data and audits on Caesarean section rates in India, and a wider debate on its potential adverse impact on the health of mothers and newborns.
This paper analyses the incidence of caesarian sections (C-sections) in Brazil. In the last decade, it has reached an extremely high level, higher than in any other country in the world. Socioeconomic and regional differences are established, using available national data on the caesarian section rate, which is higher in more prosperous regions and among wealthier women.
The different factors influencing this high incidence, including sociocultural, obstetric care organization and legal and institutional considerations are analysed. Special attention is given to the problem of female surgical sterilization, which is not officially accepted in the country, but is performed during a C-section with no other maternal or foetal indication. Consequences relating to maternal and perinatal morbidity and mortality, population fertility and the cost of health services are discussed. Interventions to reverse this trend toward higher caesarian section rates are proposed.
Brazil has one of the highest rates of caesarean section in the world. Patterns of caesarean sections were studied in a cohort of 5960 mothers followed from 1982 to 1986 in southern Brazil. Overall, 27.9% were delivered by caesarean section in 1982, this proportion being 30% for nulliparae, 80% for second deliveries when the first was by caesarean, and over 99% for third births when the first two were by caesarean. Socioeconomic status and requests for sterilisation by tubal ligation were important underlying factors. 9.4% of the women were sterilised during a caesarean section (3.7% in the lowest income group and 20.2% in the highest). 31% of women who had had their first child by a caesarean section and who were having a second operative delivery were sterilised. The high rates of caesarean sections and accompanying sterilisations reflect the lack of appropriate reproductive and contraceptive policies in the country.
616,638 births during 1967-1983 from a maternity hospital in Tehran (Iran) have been considered for the present study. The mean rate of normal delivery was 92.59%, that of Caesarean was 3.09%, that of wantose was 1.52% and finally that of forceps was 1.31%. Caesarean and wantose (vacuum extractor) delivery types showed an increasing trend, whereas the normal and forceps delivery types showed a decreased trend during the period under study. The secondary sex ratio was the highest in 1977 and the lowest in 1983 with a mean of 105.18. The twinning rate showed a decreasing trend during the above period.
Cesarean section rates have risen dramatically in the U.S. over the past 20 years. Although infant mortality has declined during the same period, there is little evidence that more frequent cesarean surgery is the cause. Cesareans save lives or benefit health in certain circumstances, but the incidence of those indications has not increased. Cesarean section also has risks, the most significant for the infant being iatrogenic prematurity or respiratory disease. Maternal mortality is 2-4 times higher and morbidity is 5-10 times higher after a cesarean compared to vaginal birth. The four indications responsible for most of the rise in cesarean rates--previous cesarean, dystocia, breech presentation, and fetal distress--are those conferring the least clear-cut benefit. Demographically, women who are most likely to experience pregnancy complications, low birth weight births, or infant mortality are least likely to have a cesarean. Social, economic, and other factors seem to have a greater influence on the decision to perform a cesarean than does expected medical benefit. The development of neonatal intensive care, expanded access to prenatal care, and greater availability of abortion and family planning have contributed more to falling infant mortality. It has been estimated that approximately half the cesareans currently performed in the U.S. are medically unnecessary, resulting in considerable avoidable maternal mortality and morbidity, and a cost of over $1 billion each year.
The rate of caesarean section (CSR) in Great Britain (GB) and the U.S.A., 12% in England in 1989 ascertained from a survey performed by the authors, and 24% according to official U.S. figures, is higher than warranted by the known and agreed obstetric indications for this operation, which suggest a rate of 6-8% would be adequate. It is argued that the fall in perinatal mortality which has occurred over the period during which the CS rate has risen is not the main reason for this fall. The training of obstetricians to deal with anxiety, provision of primary maternity care by appropriately trained midwives and general or family practitioners, and changes in management protocols could cut the CSR. The number of women undergoing surgery every year in the U.K. could be reduced by 20,000 and in the U.S.A. by 470,000 if the rate of 6% were achieved. In studies of midwifery care the CSR is even lower and it is possible that labour proceeds more efficiently if the woman knows her caregivers and labours at home, as in The Netherlands. Although CS is much safer than in the past it is still more likely to result in the death of the woman and has significant morbidity for the woman and economic costs for society.
Despite indications of high cesarean section rates in various parts of Latin America, relatively few comprehensive studies of national birth intervention trends have been conducted in that continent. Recent national statistics suggest that Chile may now have the highest reported cesarean section rate in the world. This paper examines cesarean birth trends in Chile with reference to changing patterns in health care financing.
The growth in the national cesarean birth rate is analyzed, with reference to regional patterns, differences according to insurance coverage, and recent shifts in the financing pattern of health care provision, using insurance fund data and hospital reporting systems data for both public and private sector care from the mid-1980s to mid-1990s.
Chile had a cesarean birth rate of 37.2 percent for the 301,955 births covered by either the National Health Fund or private health insurance in 1994. This was a one-third increase from the 1986 rate of 27.7 percent. The private health insurance sector revealed consistently far higher cesarean section rates than the National Health Fund sector (59% vs 28.8% in 1994); intrasectoral rates remained fairly stable over the 8-year period.
The overall increase in Chile's cesarean section rate correlates with the growth in the proportion of all births whose care was privately insured during these years (from 7.5% to 24.8%). This change may be partly explained by the doubling (to 32%) of the percentage of women with a personal obstetrician rather than a "duty" practitioner attending the birth of their baby.
To estimate the incidences of caesarean sections in Latin American countries and correlate these with socioeconomic, demographic, and healthcare variables.
Descriptive and ecological study. Setting: 19 Latin American countries.
National estimates of caesarean section rates in each country.
Seven countries had caesarean section rates below 15%. The remaining 12 countries had rates above 15% (range 16.8% to 40.0%). These 12 countries account for 81% of the deliveries in the region. A positive and significant correlation was observed between the gross national product per capita and rate of caesarean section (r(s)=0.746), and higher rates were observed in private hospitals than in public ones. Taking 15% as a medically justified accepted rate, over 850 000 unnecessary caesarean sections are performed each year in the region.
The reported figures represent an unnecessary increased risk for young women and their babies. From the economic perspective, this is a burden to health systems that work with limited budgets.